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Incidence of Glaucoma or Ocular Hypertension After Repeated Anti-Vascular Endothelial Growth Factor Injections for Macular Degeneration
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Clinical Ophthalmology (Auckland, N.Z.)
Antivascular endothelial growth factor (VEGF) drugs have become widely known for sparking a revolution in the treatment of several diseases of the posterior segment including neovascular age-related macular degeneration (AMD), retinal vein occlusions, and diabetic retinopathy. Sustained intraocular pressure (IOP) elevation following repetitive anti-VEGF injections will continue to be an important area of research. Theories include that of a permanent decrease in outflow facility due to repeated spikes in IOP after each injection that damage the trabecular meshwork, direct pharmacological toxicity, and chronic trabeculitis. Post hoc analysis showed that 2.1% of eyes in the MARINA and 3.6% of eyes in the ANCHOR trials met the criteria for long-term IOP rise at the 2-year follow-up.
This retrospective chart review study included patients who received unilateral anti-VEGF injections but in whom both eyes could be analyzed to determine ocular hypertension (OHT) or open-angle glaucoma (OAG) development. Of the 1078 patients who met the study criteria, 40 patients (3.71%) developed OHT or OAG in only the injected eye, as opposed to 21 patients (1.95%) who developed OHT or OAG in both eyes, over an average follow up period of 32.01 ± 23.3 months. The higher rate of injections was associated with a higher incidence of sustained IOP elevation. Of the patients who received 25 or more injections, 36.7% developed OHT or OAG in the injected eye.
This study emphasizes the mechanical theory of outflow system damage associated with repeated injection of a volume into the posterior segment. Interestingly, pseudophakic eyes were found to be at a greatly reduced risk of disease development compared with phakic eyes. This can be explained by the outflow system strain reduction in pseudophakic eyes that results from a widely open anterior chamber angle and rapid volume equilibration from the posterior to anterior chamber through the zonules.
Further research is needed to establish the long-term effects of anti-VEGF injections on measurements related to glaucomatous disease, such as optical coherence tomography retinal nerve fiber (OCT RNFL) thickness, electrophysiology, and visual field loss progression.